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Chronic opioid therapy issues associated with opioid abuse potential

Howard S. Smith, MD, Kenneth L. Kirsh, PhD, Steven D. Passik, PhD


Chronic opioid therapy continues to be an important “mainstream” option for the relief of pain, despite continued debate over the efficacy and safety of utilizing opioids with chronic noncancer populations. With this increase in utilization for medical purposes, the authors have also experienced a troubling rise in the abuse and diversion of prescription opioids. Providers should note this relationship and always perform due diligence when assessing whether a patient with chronic noncancer pain is an appropriate candidate for opioid therapy based on potential risk factors. Because of the relative shortage of board-certified pain practitioners in the United States, much of the practice of pain management falls on primary care providers, who might feel uncomfortable or overwhelmed when facing these issues. To this end, a set of guidelines are discussed to promote an approach to chronic noncancer pain utilizing “universal precautions” principles. In addition, several risk tools are evaluated, including the Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R), the Opioid Risk Tool (ORT), and the Pain Assessment and Documentation Tool (PADT). Finally, discussion is presented regarding what practices seen in opioid prescribing can be considered “in-or-out” of the mainstream box.


opioids, drug abuse, prescribing, risk, screening

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Nyswander ME, Dole VP: On the use of methadone to limit physical dependence in the treatment of chronic pain. In Foley KM, Inturrisi CE (eds.): Advances in Pain Research and Therapy, Vol. 8. New York, NY: Raven Press, 1986: 187-190.

Portenoy RK, Foley KM: Chronic use of opioid analgesics in non-malignant pain: Report of 38 cases. Pain. 1986; 25(2): 171-186.

Melzack R: The tragedy of needless pain. Sci Am. 1990; 262(2): 27-33.

Rosenblum A, Marsch LA, Joseph H, et al.: Opioids and the treatment of chronic pain: Controversies, current status, and future directions. Exp Clin Psychopharmacol. 2008; 16(5): 405-416.

Ballantyne JC: Regulation of opioid prescribing. Over-regulation compromises doctors’ ability to treat pain. BJM. 2007; 334(7598): 811-812.

Reid MC, Engles-Horton LL, Weber MB, et al.: Use of opioid medications for chronic noncancer pain syndromes in primary care. J Gen Intern Med. 2002; 17(3): 173-179.

Soderstrom CA, Dischinger PC, Kerns TJ, et al.: Epidemic increases in cocaine and opioid use by trauma center patients: Documentation with a large clinical toxicology database. J Trauma. 2001; 51(3): 557-564.

Gilson AM, Ryan KM, Joranson DE, et al.: A reassessment of trends in the medical use and abuse of opioid analgesics and implications for diversion control: 1997-2002. J Pain Symptom Manage. 2004; 28(2): 176-188.

Fishbain DA, Rosomoff HL, Rosomoff RS: Drug abuse, dependence, and addiction in chronic pain patients. Clin J Pain. 1992; 8(2): 77-85.

Katon W: Somatization in primary care. J Fam Pract. 1985; 21(4): 257-258.

Katz N, Fanciullo GJ: Role of urine toxicology testing in the management of chronic opioid therapy. Clin J Pain. 2002; 18(4 suppl): S76-S82.

Martell BA, O’Connor PG, Kerns RD, et al.: Systematic review: Opioid treatment for chronic back pain: prevalence, efficacy, and association with addiction. Ann Intern Med. 2007; 146(2): 166-127.

Chou R, Fanciullo GJ, Fine PG, et al.: Opioid treatment guidelines. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009; 10(2): 113-130.

American Academy of Pain Medicine, American Pain Society: The use of opioids for the treatment of chronic pain. Pain Consultants of Atlanta Web site. Available at Accessed August 4, 2004.

World Health Organization. Achieving Balance in National Opioids Control Policy: Guidelines for Assessment. Geneva: WHO, 2000.

Zacny J, Bigelow G, Compton P, et al.: College on problems of drug dependence taskforce on prescription opioid non-medical use and abuse: Position statement. Drug Alcohol Depend. 2003; 69(3): 215-232.

Biomedical Computing Group: Joint statement from 21 health organizations and the Drug Enforcement Administration. Promoting pain relief and preventing abuse of pain medications: A critical balancing act. Biomedical Computing Group, University of Wisconsin Medical School Web site. Available at 2.pdf. Accessed August 4, 2004.

Brown RL, Rounds LA: Conjoint screening questionnaires for alcohol and other drug abuse: Criterion validity in a primary

care practice. Wisc Med J. 1995; 94(3): 135-140.

Brown RL, Leonard T, Saunders A, et al.: A two-item screening test for alcohol and other drug problems. J Fam Pract. 1997; 44(2): 151-160.

Compton P, Darakjian J, Miotto K: Screening for addiction in patients with chronic pain and “problematic” substance use: Evaluation of a pilot assessment tool. J Pain Symptom Manage. 1998; 1(6): 355-363.

Holmes CP, Gatchel RJ, Adams LL, et al.: An opioid screening instrument: Long-term evaluation of the utility of the pain medication questionnaire. Pain Pract. 2006; 6(2): 74-88.

Lin JJ, David A, Moore C: Physician attitudes toward opioid prescribing for patients with persistent noncancer pain. Clin J Pain. 2007; 23(9): 799-803.

Braden JB, Fan M-Y, Edlund MJ, et al.: Trends in use of opioids by noncancer pain type 2000-2005 among Arkansas Medicaid and HealthCore enrollees: Results from the TROUP study. J Pain. 2008; 9(11): 1026-1035.

Gourlay DL, Heit HA: Universal precautions in pain medicine: A rational approach to the treatment of chronic pain. Pain Med. 2005; 6(2): 107-112.

Gourlay D, Heit H: Universal precautions: A matter of mutual trust and responsibility. Pain Med. 2006; 7(2): 210-211; author reply 212.

Smith HS, Kirsh KL: Identifying and managing the risk of opioid misuse. Therapy. 2009; 6(5): 685-693.

Smith HS: Goal-directed therapy agreements. J Cancer Pain Symptom Palliat. 2006; 1(3): 11-13.

Passik SD, Kirsh KL, Casper D: Addiction-related assessment tools and pain management: Instruments for screening, treatment planning, and monitoring compliance. Pain Med. 2008; 9(S2): S145-S166.

Yudko E, Lozhkina O, Fouts A: A comprehensive review of the psychometric properties of the drug abuse screening test. J Subst Abuse Treat. 2007; 32(2): 189-198.

Coambs RB, Jarry JL: The SISAP: A new screening instrument for identifying potential opioid abusers in the management of chronic nonmalignant pain in general medical practice. Pain Res Manage. 1996; 1(3): 155-162.

Belgrade MJ, Schamber CD, Lindgren BR: The DIRE score: Predicting outcomes of opioid prescribing for chronic pain. J Pain. 2006; 7(9): 671-681.

Butler SF, Fernandez K, Benoit C, et al.: Validation of the revised screened and opioid assessment for patients with pain (SOAPP-R). J Pain. 2008; 9(4): 360-372.

Webster LR, Webster RM: Predicting aberrant behaviors in opioid-treated patients: Preliminary validation of the opioid risk tool. Pain Med. 2005; 6(6): 432-442.

Passik SD, Weinreb HJ: Managing chronic nonmalignant pain: Overcoming obstacles to the use of opioids. Adv Ther. 2000; 17(2): 70-80.

Smith HS: The numerical opioid side effect (NOSE) assessment tool. J Cancer Pain Symptom Palliat. 2006; 1(3): 3-6.

Passik SD, Kirsh KL, Whitcomb LA, et al: A new tool to assess and document pain outcomes in chronic pain patients receiving opioid therapy. Clin Ther. 2004; 26(4): 552-561.

Passik SD, Kirsh KL, Whitcomb LA, et al.: Monitoring outcomes during long-term opioid therapy for non-cancer pain: Results with the pain assessment and documentation tool. J Opioid Manag. 2005; 1(5): 257-266.

Butler SF, Budman SH, Fernandez KC, et al.: Development and validation of the current opioid misuse measure. Pain. 2007; 130(1-2): 144-156.

Passik SD, Kirsh KL, Konaghy KB, et al.: Pain and aberrant drug-related behaviors in medically ill patients with and without histories of substance abuse. Clin J Pain. 2006; 22(2): 173-181.

Wu SM, Compton P, Bolus R, et al.: The addiction behaviors checklist: Validation of a new clinician-based measure of inappropriate opioid use in chronic pain. J Pain Symptom Manage. 2006; 3(4): 342-351.

Turk DC, Swanson KS, Gatchel RJ: Predicting opioid misuse by chronic pain patients: A systematic review and literature synthesis. Clin J Pain. 2008; 24(6): 497-508.

Friedman R, Li V, Mehrotra D: Treating pain patients at risk: Evaluation of a screening tool in opioid-treated pain patients with and without addiction. Pain Med. 2003; 4(2): 182-185.

Michna E, Ross EL, Hynes WL, et al.: Predicting aberrant drug behavior in patients treated for chronic pain: Importance of abuse history. J Pain Symptom Manage. 2004; 28(3): 250-258.

Adams LL, Gatchel RJ, Robinson RC, et al.: Development of a self-report screening instrument for assessing potential opioid medication misuse in chronic pain patients. J Pain Symptom Manage. 2004; 27(5): 440-459.

Butler SF, Budman SH, Fernandez K, et al.: Validation of a screener and opioid assessment measure for patients with chronic pain. Pain. 2004; 112(1-2): 65-75.

Chou R, Fanciullo GJ, Fine PG, et al.: Opioids for chronic noncancer pain: prediction and identification of aberrant drugrelated behaviors: A review of the evidence for an American Pain Society and American Academy of Pain Medicine clinical practice guideline. J Pain. 2009; 10(2): 131-146.

Passik SD, Kirsh KL: The interface between pain and drug abuse and the evolution of strategies to optimize pain management while minimizing drug abuse. Exp Clin Psychopharmacol. 2008; 16(5): 400-404.

Ballantyne JC, Mao J: Opioid therapy for chronic pain. N Engl J Med. 2003; 349(20): 1943-1953.

Haythornthwaite JA, Menefee LA, Quatrano-Piacentini AL, et al.: Outcome of chronic opioid therapy for non-cancer pain. J Pain Symptom Manage. 1998; 15(3): 185-194.

Raja SN, Haythornthwaite JA, Pappagallo M, et al.: Opioids versus antidepressants in postherpetic neuralgia. A randomized, placebo-controlled trial. Neurology. 2002; 59(7): 1015-1021.

Fishman SM, Webster LR: Unintended harm from opioid prescribing guidelines. Pain Med. 2009; 10(2): 285-286.

Weissman DE, Haddox JD: Opioid pseudoaddiction–An iatrogenic syndrome. Pain. 1989; 36(3): 363-366.

Pappagallo M: The concept of pseudotolerance to opioids. J Pharm Care Pain Symptom Control. 1998; 6(2): 95-98.

Smith, HS: Opioid metabolism: A review. Mayo Clinic Proc. 2009; 84(7): 613-624.

Smith HS: Variations in opioid responsiveness. Pain Physician. 2008; 11(2): 237-248.

Smith HS: Combination opioid analgesics. Pain Physician. 2008; 11(2): 201-214.

Smith HS, Deer TR, Staats PS, et al.: Intrethecal drug delivery. Opioid special issue. Pain Physician. 2008; 11(S2): S89-S104.

Katz NP, Adams ED, Benneyan JC, et al.: Foundations of opioid risk management. Clin J Pain. 2007; 23(2): 103-118.

Katz NP, Buse DC, Budman SH, et al.: Development and preliminary experience with an ease of extractability rating for prescription opioids. Drug Dev Ind Pharm. 2006; 32(6): 727-746.

Butler SF, Benoit C, Budman SH, et al.: Development and validation of an opioid attractiveness A scale: A novel measure of the attractiveness of opioid products to potential abusers. Harm Reduct J. 2006; 3: 5.

Bieber CM, Fernandez K, Borsook D, et al.: Retrospective accounts of initial subjective effects of opioids in patients treated for pain who do or do not develop opioid addiction: a pilot case-control study. Exp Clin Psychopharmacol. 2008; 16(5): 429-434.

Butler S, Black R, Grimes Serrano J, et al: Estimating attractiveness of a not-yet-marketed abuse deterrent opioid analgesic. J Pain. 2009; 10(Suppl 1): S11.

Webster LR, Bath B, Medve RA: Opioid formulations in development designed to curtail abuse: Who is the target? Expert Opin Investig Drugs. 2009; 18(3): 255-263.

Katz N: Abuse-deterrent opioid formulations: are they a pipe dream? Curr Rheumatol Rep. 2008; 10(1): 11-18.

Smith HS: Enteral controlled-release opioid delivery systems. Pain Med. (Oxymorphone Issue) 2009; 10(S1): S30-S38.

Budman S, Black R, Cassidy T, et al.: DETER™: Dynamic evaluation and timely estimates of Rx opioid routes of administration and abuse deterrence. J Pain. 2009; 10(Suppl 1): S11.



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